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Injury, Int. J.

Care Injured (2005) 36, S-A51S-A56

Concept of treatment in supracondylar humeral fractures


Richard A.K. Reynolds, Holly Jackson
Keck School of Medicine, University of Southern California, Childrens Hospital Los Angeles, USA

KEYWORDS:
Supracondylar humeral fracture; technique; children.

Summary1 This opinion of treatment for childrens supracondylar humeral fractures discusses techniques of fracture reduction and stabilization. A useful method of external visualization of the fracture is reviewed. The article discusses the treatment of 95 fractures in children using crossed and two lateral pin techniques.

Introduction
There have been few areas of childhood fracture management that have generated as much angst and trepidation as the supracondylar humeral (SCH) fracture. On average, 15 articles per year are generated describing the best method of fracture care or questioning the methods used to treat this common and worrisome fracture. This fracture has an impressive pedigree of devastating complications ascribed to it including amputation, compartment syndrome, severe deformity, and permanent disability. What could possibly be written to further the knowledge of treating the SCH fracture? Despite the many articles written on this subject, it can nevertheless be useful to try and make the apparently complicated treatment of this fracture as easy as possible and to apply some general principles that take some of the angst out of this fracture.

Treatment principles
The general principles of fracture management apply to this fracture such as determining associated injuries that may complicate the treatment of the patient and therefore the treatment of the fracture:
1

Abstracts in German, French, Italian, Spanish, Japanese, and Russian are printed at the end of this supplement.

Is the fracture open or closed? Is there an associated neurological or vascular injury? Is the patient splinted? The fracture needs to be reduced and stabilized to maximize the vascular supply and circulation of fluid in the arm. There are two problems of inflow and outflow that need to be addressed. In many ways, the inflow is much more tolerant with a high pressure system with many collateral inflow channels. The outflow system, however, is much more sensitive and can cause many problems ranging from compartment syndrome to severe swelling that causes fracture blisters. The best method of treating the outflow problems is to obtain and maintain skeletal alignment and stability, with the arm in a position that maximizes outflow (relaxed flexion). The historical treatment of reduction and casting of this periarticular fracture has shown us what venous obstruction can result in, ie, Volkmans ischemic contracture. Surgical treatment of this fracture has reduced the problem of venous outflow greatly, but has resulted in its own set of complications. The problems of putting pins in a small bone that is surrounded by a fat swollen soft-tissue envelope are many wit the potential for damage to various periarticular structures due to errant pin placement. The position of relaxed flexion maximizes softtissue management but is not a skeletally stable position. The whole stability of the fracture depends

00201383/$ see front matter 2004 Published by Elsevier Ltd. doi:10.1016/j.injury.2004.12.013

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on the proper placement of pins in a strong enough position to prevent displacement of the fracture. Pin placement is key to the success of the skeletal alignment and function. In general, the stability depends on three factors that are under the control of the surgeon: 1) Size of the pin, 2) the distance between the pins along the line of the fracture, 3) the pins being in the bone on both sides of the fracture.

Methods
Closed reduction There are seven steps to reducing the extension type fractures that are most commonly encountered. The approach should be done in the same way to minimize variations in technique and maximize success. The following approach is used in training residents at our facility for two series of 50 (100) consecutive fractures [2]. 1. The patient is positioned on the table with their head over the side of the table on the arm board and the shoulder is abducted to allow the elbow to be imaged. 2. The image intensifier is placed at the head of the table above the arm board, parallel to the long axis of the OR table. This position keeps the machine out of the way during the reduction and fixation. 3. Image the fracture to allow full understanding of the fracture pattern, since the preoperative x-rays are often of poor quality and can be confusing. (AP, lateral and two oblique views).

4. Longitudinal traction is then applied to the fracture in the position of injury. Do not hyperextend the fracture; since the fracture fragments must be disengaged, hyperextension can injure the median nerve and brachial artery by tensioning these structures over the proximal fragment. Check the fracture by imaging while traction is being applied. 5. Correct the medial and lateral displacement by pushing the medial or lateral aspect of the distal fragment; correlate the position of the fracture under imaging. 6. To correct the rotational deformity, flex the elbow 1520; stabilize the proximal shaft of the humerus with one hand while correcting the deformity with the other. Externally rotate the distal fragment if the fragment was displaced posteromedially on the initial x-rays; internally rotate if the initial displacement was posterolateral. 7. To correct the extension deformity, begin by flexing the elbow to at least 130 and pronate the forearm, resulting in a successful reduction. Inability to achieve flexion requires repetition of the reduction maneuvers described above (Fig. 1). 8. Secure the arm in the reduced position with tape. The tape can be an adhesive tape or Coban, a self adhering bandage. A sterile towel is wrapped around the arm distal to the tape. A sterile extremity drape or split drape is then applied. 9. The visual cues are applied to the arm to facilitate pin placement [2].

Fig. 1: The patients fracture is reduced and taped in the hyperflexed position.

Fig. 2: The line is drawn along the plane of the humerus and extended to the lateral side of the arm.

Concept of treatment in supracondylar humeral fractures

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Percutaneous pinning technique Crossed pins A sterile extremity or split drape is applied, and the visual cues are then applied to facilitate pin placement [2]. In the lateral view, externally rotate the arm until the teardrop is seen on the end. A K-wire is then placed over the arm to bisect the bone along its axis (Fig. 2). A line is then applied and extended from the medial side of the arm across the end of the arm. From the anteroposterior view, the medial and lateral columns are found, and the K-wire is placed along the desired trajectory of the pin. A line is then drawn on the arm to give the visual cue and the line is extended to bisect the line previously drawn along the long axis of the arm. The lateral pin is placed with the entry point being where the two lines bisect and is inserted in a plane parallel to the lines. Resistance should be felt. The position is checked with the image intensifier (Fig. 3). The medial pin is the most worrisome due to the ulnar nerve. The medial pin placement has some alternative methods for placement. According to Kasser, the mobility of the ulnar nerve is common and as a result the placement of the medial pin with the elbow flexed causes nerve injury due to anterior subluxation of the nerve. This has not been my experience but to take this into account the medial pin can be placed under radiographic control with the elbow flexed or extended once the fracture has been partially stabilized with the lateral pin. The entry point is in line with, but slightly anterior to, the medial epicondyle. The pin is used to feel the anterior aspect of the prominent medial epicondyle.

The position is checked on the lateral view prior to pin insertion. The pin is introduced at 90 along the long axis of the humerus; however, after breaching the cortex, it is angled at 45. The desired plane of insertion has been defined by the lateral pin. Be sure that the medial pin is distal enough to catch the fracture fragment. Once the pins have been inserted, confirm pin placement and alignment under imaging. If it is satisfactory, then the stability can be checked. Undrape the extremity, release the tape and extend the elbow. Check for motion at the fracture site in four views, and in both flexion and extension. Two lateral pins The technique is the same as above for placing the lines on the arm to allow for external visual cues. These cues allow better hand-eye orientation for the inexperienced and the occasional stabilizer of elbow fractures. The difference is the placement of divergent pins and the use of the olecranon fossa to get better purchase of the distal fragment. The divergent pins allow for better distance between the pins as they cross the fracture. If the medially directed pin goes through the olecranon fossa, it captures two cortices in the bone near the fracture. This stiffens the construct and potentially prevents the pin from moving in the soft cancellous bone. The imperative part of the fixation is in the medial proximal portion. Missing this cortex makes loss of rotational reduction probable. Ensure resistance is felt with this pin.

Fig. 3: The pins are placed along the line that is formed by the two intersecting planes.

Fig. 4: The insertion points for the pin are shown above.

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Results Crossed pins (46 patients) [2] Four patients out of 46 developed ulnar neuropraxia postoperatively. Three of four patients had ulnar sensory neuropraxia but recovered within 24 hours of the pinning. The symptom was altered sensation to light touch. One of four patients had a motor and sensory neuropraxia that recovered by eight weeks post-pinning. Two patients developed a mild cubitus varus, due to comminution of the medial column; no surgical intervention was required. One patient had an

absent radial pulse with a well-perfused hand. The pulse had recovered at the initial follow-up. The lateral pin in one patient migrated under the skin and required removal in the operating room. The possible complications of myositis ossificans and premature physeal arrest were not present in any of the cases reviewed. Lateral pins (50 patients) The results of the patients treated with two lateral pins were very similar to the crossed pins group (Figs. 5, 6, 7, 8).

Fig. 5: This is a displaced Gartland type 3 supracondylar humerus fracture pre-reduction. Note the completely displaced and rotated distal fragment. The proximal fragment is tenting the skin anteriorly.

Fig. 7: This is the lateral view, note the pin fixation is centered in the lateral view, which ensures the proximal fixation is in bone.

Fig. 6: This is a post reduction view of the same patient. Note the divergent pin placement. The more medial pin is penetrating the olecranon fossa.

Fig. 8: The arm is placed in a well-padded splint in 45 of flexion.

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There were 50 consecutive patients treated by residents under supervision. The group was 50% male with 21/50 Type II and 29/50 Type III fractures. The number of attempts per pin was 12 with two pins used per fracture. The median operative time was 25 min and there were no complications. The technique is sometimes blamed for failure caused by badly placed pins (Fig. 9).

ment. The fracture should be approached from the anterior lateral direction; the fracture is aligned using the anterior cortex. Any soft tissue interposed can be removed with good visualization. The circumferential stripping of the fragments can and will result in vascular injury to the epiphysis; so careful and thoughtful planning should be done preoperatively.

Compartment syndrome One patient developed a compartment due to an intimal tear that became occluded postoperatively. There was no postoperative neuropraxia or loss of reduction. Open reduction Open reduction is a very rare occurrence in our facility, which sees approximately 300400 fractures around the elbow per year. Indications for open reduction include open injuries, vascular injuries, surgically induced neuropraxia, and irreducible fractures. The direction of the surgical approach should take into account the surgeons familiarity with the approach, the fracture pattern, and the unique blood supply of the pediatric distal humerus. The lateral approach to the elbow is very common and most surgeons should be familiar with it. The unique blood supply of the distal humerus is that the posterior based blood vessels supply the epiphysis. These vessels are usually preserved in an extension type SCH fracture. The lateral approach not dissect the posterior aspect of the fracture frag-

Common approaches or combination of approaches Lateral: most common, good visualization, good familiarity. Medial: less common, good for medial injuries, better cosmesis, need to mobilize ulnar nerve, less familiar approach for most. Posterior: most common in adult elbow fractures, potential vascular compromise to epiphysis, good visualization but not recommended in younger children. Anterior: good for vascular injuries, can be extended for compartment releases, less cosmetic, does not have a good combination approach. Lateral and medial: most common combination of approaches, gives good visualization, can preserve blood supply to epiphysis. Lateral-medial-posterior: combination should not be done.

Controversies Vascular injuries When do you explore the artery? The data seems to support exploration when there is loss of circulation to the point that the temperature and color of the hand is sufficiently impaired to cause the hand to be cool and pale. The hand seems to tolerate interruption of the brachial artery if collateral circulation is good enough to have a warm perfused hand [1]. What is the role for closed treatment and casting? As management evolves, closed treatment and casting for displaced humerus fractures is becoming less common. The more severe complications of vascular compromise due to casting and hyperflexion of the arm are being eliminated with pin stabilization and post operative positioning in relaxed flexion. The place for closed reduction and casting is most appropriate for incomplete stable fractures with the position of the arm at no more than 90 of flexion to facilitate outflow of blood and edema [3].

Fig. 9: This is an example of how not to pin the fracture. Note how the pins are too close together and not divergent, which may allow the fracture to rotate and lose the reduction.

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Crossed versus lateral pinning? Clinical reviews of lateral pinning series with minimal differences in outcomes of fracture care between the two groups increasingly show mounting evidence of no iatrogenic nerve injuries with lateral pinning technique [4, 5]. There may be some losses of reduction in the lateral pinning technique, but they can be minimized using larger pins and improving fixation in the fragments [6].

References
1. Gosens T, Bongers KJ (2003) Neurovascular complications and functional outcome in displaced supracondylar fractures of the humerus in children. Injury: 34(4):267273. 2. Reynolds RA, Mirzayan R (2000) A technique to determine proper pin placement of crossed pins in supracondylar fractures of the elbow. J Pediatr Orthop; 20(4):485489. 3. Shoaib M, Hussain A, Kamran H, et al (2003) Outcome of closed reduction and casting in displaced supracondylar fractures of humerus in children. J Ayub Med Coll Abottabad; 15(4):2325. 4. Skaggs DL, Kay RM, Tolo VT (2002) Fracture stability after pinning of displaced supracondylar distal humerus fractures in children. J Pediatr Orthop; 22(5):697; author reply 697698. 5. Skaggs DL, Hale JM, Bassett J, et al (2001) Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Am; 83-A(5):735740. 6. Zionts LE, McKellop HA, Hathaway R (1994) Torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. J Bone Joint Surg Am; 76(2):253256.

Timing of surgery? There have been some papers that purport delay of surgery in SCH fractures with no deleterious effects. These papers are useful; delay of treatment may suit your institution due to personnel and equipment availability. In order to delay treatment overnight it is essential that the limb is neurovascular intact, the injury is closed, the limb is comfortably splinted, and there is an adequately staffed trauma theatre with an image intensifier available early the next morning. After considering these factors, the treating surgeon must decide when it is most practical and safe to treat these difficult fractures. A simple, repeatable procedure is desirable when infrequently dealing with such a complicated fracture.

Correspondence address: Prof. Richard A.K. Reynolds Associate Professor of Orthopedics Keck School of Medicine University of Southern California Childrens Hospital Los Angeles, USA email: rreynolds@chla.usc.edu

Conclusion
Supracondylar humerus fractures are difficult injuries to treat for surgeons who see them infrequently. Our approach works quite well for resident teaching and gives the operating surgeon some external cues to help position the pins properly. A simple, repeatable procedure is desirable when infrequently dealing with such a complicated fracture.